1 Training Session 3b: Broad Knowledge of Treatment Settings and Resources for Persons with TBI and their Families during Different Phases of Service Requirements. Treatment Settings for Rehabilitation Services National Brain Injury Organizations Transportation Resources Sources of Financial Support References
2 Treatment Settings for Rehabilitation Services: Rehabilitation services are provided in a variety of treatment settings. The appropriate treatment setting for your client may vary depending on factors such as: time post-injury, severity of injury, rehabilitation goals, and availability of services within the community. Initially after injury, your client may be receiving services in an acute-care hospital rehabilitation setting, while many months or years after injury, your client may receive services in a community-based setting. The following is a brief description of some of the service settings through which your client with TBI may receive rehabilitation. Acute-care hospital rehabilitation services: Rehabilitation services (typically occupational therapy, physical therapy and speech therapy) are provided to the client at the earliest possible moment post-injury. Goals can include promoting range of motion, swallowing, speech, and basic activities of daily living. Rehabilitation services can even be offered within the intensive care setting or can be provided within an acute-care ward. Within the acute hospital setting, it is typically the case that rehabilitation is limited, due to the inherent focus on medical/surgical issues that are often more pressing at this time point. Furthermore, rehabilitation in the acute-care setting is seldom interdisciplinary in approach, and specialties tend to operate separately from each other. The high costs of services within the acute care treatment setting may lead to limited service availability. Acute Rehabilitation: When one thinks about inpatient rehabilitation for patients with TBI, the gold standard model for intensive inpatient rehabilitation care in the US is comprehensive integrated medical rehabilitation. 1 As defined by the Commission on Accreditation of Rehabilitation Facilities (CARF), a Comprehensive Integrated Inpatient Rehabilitation Program is a program of coordinated and integrated medical and rehabilitation services that is provided 24 hours a day and endorses the active participation and preferences of the person served throughout the entire program. The preadmission assessment of the person served determines the program and setting that will best meet the needs of the person served. The person served, in collaboration with the interdisciplinary team members, identifies and addresses his or her medical and rehabilitation needs. The individual resource needs and predicted outcomes of the person served drive the appropriate use of the rehabilitation continuum of services, the provision of care, the composition of the interdisciplinary team, and discharge to the community of choice.
3 The scope and intensity of care provided are based on a medical and rehabilitation preadmission assessment of the person served. An integrated interdisciplinary team approach is reflected throughout all activities. To ensure the transparency of information the program provides a disclosure statement to each person served that addresses the scope and intensity of care that will be provided. 2 Typically, this setting provides a comprehensive scope of care that is supervised by a physiatrist or other rehabilitation physician and offers 3 or more hours of therapy per day provided within interdisciplinary format. Such programs offer 24-hr per day rehabilitation nursing who perform traditional nursing tasks and functional training carryover into nontherapy hours. It is often at the time in which clients are admitted to a comprehensive inpatient brain injury rehabilitation program that future vocational needs begin to be considered and involvement of a vocational counselor may be initiated. Extended Care Facilities: For clients who are not ready for community-based services and are not capable of tolerating the level of care provided in a comprehensive inpatient brain injury rehabilitation program, the least costly alternative is an extended care facility (ECF) or nursing home. 1 While clients that are treated within these settings are typically not receiving vocational rehabilitation services, it is possible that clients treated in an ECF may be vocational rehabilitation candidates at a later point in their recovery. To increase your understanding of the care which may be provided at an ECF, clients may receive basic custodial care, limited medical supervision, and minimal therapy (OT, PT,ST, etc.) services. At such facilities, staff will be able to maintain feedings and hydrations, and can assist with a bowel/bladder management program to some extent. 1 The population within ECFs is prone to neuromedical complications and preventive medical and rehabilitation systems are often limited. Staffing is typically at about 3 nursing hours per patient, which limits the care that can be received. Limitations in the amount of movement received in these settings can contribute to complications like infection, skin breakdown, spasticity, contracture, heterotopic ossification, gastrointestinal motility disorders, and respiratory dysfunction. Medical care rarely involves physiatrists and is of limited frequency. Intermediate Rehabilitation: For other clients who are not ready for a comprehensive inpatient brain injury rehabilitation program, but can manage to participate in active rehabilitation, an intermediate rehabilitation treatment setting may be optimal. This setting provides a treatment intensity that is somewhere between that provided in a comprehensive program and an ECF. Intermediate rehabilitation involves two separate levels of care: subacute medical care and subacute
4 rehabilitation. 1 Subacute medical care manages medically stable pts who have ongoing medical needs too complex for an ECF setting or for home care (e.g., wound care cases, ventilator pts, IV therapy). Rehabilitation goals are secondary to the medical treatment needs. Subacute rehabilitation programs were developed to serve medical rehabilitation needs of frail or medically complex geriatric patients. Programs vary but offer the commonalities of varying levels of physical therapy, occupational therapy, and speech therapy. Rehabilitation services are offered on a less frequent and intense nature than would be the case in comprehensive inpatient rehabilitation programs, with the goal focused on maximizing functional status and discharge to community. 1 Again, those treated within subacute rehabilitation settings are unlikely to have immediate vocational goals; however, a subset of such individuals may become vocational candidates further along in their recovery. Transitional Medical Rehabilitation: Another option for those patients with TBI who are between the needs of acute-care hospitalization and acute rehabilitation is the transitional medical rehabilitation program. This program is typically offered within acute care hospital settings, providing a lower intensity of service than a comprehensive program and lower cost than a program offered in an intensive care setting, yet offers services within an interdisciplinary team framework. 1 Home Care: For those lower-level patients who are unable to participate in a comprehensive inpatient rehabilitation program, a further option is to receive services within the home setting. This may be ideal from some perspective, in that the client is able to leave costly hospital setting and can have frequent daily contact with family and loved ones. However, those patients with ongoing medical complexity and intensive physical and cognitive assistance needs may be difficult for many families to manage. Such patients may need frequent feedings, pulmonary care, toileting, bowel and bladder programs, or repositioning to prevent contractures and bedsores, for example. Providing such care may prevent some family members from being able to work or participate in regular recreational and social activities. Even when the family is willing to provide such care, extensive and comprehensive family-caregiver training is necessary. Even the best training may not be adequate for some situations, such as the development of pressure sores, respiratory distress, infections, or worsening spasticity. Coordinating home therapies from outside agencies can be difficult and third party insurers are often unwilling to pay for home services.
5 Post-Acute Rehabilitation: Vocational counselors are most often involved in the rehabilitation process for clients with TBI in the post-acute period. Once the initial medical issues have been addressed and clients are at a more stable phase of recovery, considerations about maximizing a return to employment, school, and community life begin to predominate. Post-acute rehabilitation services can be offered in a variety of settings, including: Comprehensive day treatment programs: Such programs offer integrated, multimodal rehabilitation typically delivered by an interdisciplinary team approach. Day Treatment Program: A day treatment program is typically a self-contained program at a particular center to which clients come to receive a variety of outpatient therapy services. Therapies are conducted within the treatment setting and clients may attend daily or at a lesser frequency, depending on their individual treatment needs. Community Re-Entry Program: A community re-entry program also provides a variety of therapy services on an outpatient basis; however, there is an emphasis on transitioning skills learned within the treatment center to the community. Clients will frequently participate in vocational, social, and daily living skills activities within the community through options like volunteer work placements, shopping trips to the grocery store or mall, our outings at restaurants. In these real-world settings, clients have the opportunity to practice and implement strategies used to compensate for areas of cognitive and/or behavioral difficulty. Neurobehavioral Program: Neurobehavioral programs are typically residential programs that provide intense behavioral treatment to clients with brain injury who express severe behavioral disturbances. This more secure setting is designed to provide a safe haven for clients to learn to manage behavioral difficulties with the goal of eventual return to the community setting. An emphasis on behavioral management programs and medical management of behavioral disorders is present, in addition to physical, occupational, and cognitive rehabilitation services. Vocational counselors are often an integral part of the treatment team and assist the client in identifying jobs that match the client s cognitive and behavioral strengths, as well as assisting with developing and implementing a behavioral management approach within the work setting. Residential community reintegration programs: Another post-acute treatment setting is the transitional living program, which provides integrated cognitive, emotional, behavioral, physical, and vocational rehabilitation to clients who cannot participate in an outpatient program due to factor such as severe cognitive or
6 behavioral impairment, unavailability of services within the client s own community, or unwillingness of the family to house the client within the home. Community-based treatment: More recently, there has been an increasing emphasis on the provision of rehabilitation services directly within the client s community. Rather than attending therapies in a clinic setting and transitioning those strategies to the community, the client is treated entirely within his or her own community (i.e, in his or her home, workplace, and local community). Return to top or Continue
7 National Brain Injury Organizations Knowledge of appropriate local, state, and national resources could help direct persons with TBI and their family members to agencies and services that may additionally improve their community participation and quality of life. There are two important national organizations that may be of use: one is the Brain Injury Association of America (BIAA) and the other is the North American Brain Injury Society (NABIS). A brief description of these organizations follows: Brain Injury Association of America: The Brain Injury Association of America (BIAA) was formed in 1980 to be the leading national organization serving and representing individuals, families and professionals who are affected by TBI. The organization has a network of more than 40 chartered state affiliates, as well as hundreds of local chapters and support groups across the country. The objectives of the organization are to provide information, education, and support to assist the 5.3 million Americans currently living with TBI and their families. You can contact the BIAA at for information and resources and/or visit: Through this website or via the phone number, you can also gain contact information for your local State Chapter for the Brain Injury Association of America. Your State Chapter can be a vital source of information about local brain injury educational events; legislative agenda issues of interest to clients with brain injury; and local, state, and regional resources. North American Brain Injury Society: The North American Brain Injury Society (NABIS) was founded in 2003 as the American chapter for the International Brain Injury Association (IBIA). NABIS is a society made up of professional members who are involved in the care or services of persons with brain injury. The main focus of NABIS is to work toward the translation of brain injury research into clinical practice. This focus is specifically addressed through the provision of educational programs and scientific updates. Each year NABIS holds a brain injury conference with featured national and international speakers providing education on a wide variety of topics relevant to clients with TBI. Employment and return to work issues are always featured at such events, and can be a good source of continuing education. Additional, NABIS produces a journal entitled Brain Injury Professional, which provides great resource information. You can contact NABIS at or , and/or visit: Return to top or Continue
8 Transportation resources Due to changes in vision, motor functioning, and cognition, your client may not be ready or able to return to driving. Arrangements for transportation to and from appointments with you, the workplace, and/or treatment providers you refer your client to may be necessary. Planning for long-term transportation needs will be an important aspect of planning to maximize vocational success. If your client is considering return to driving, you may wish to refer him or her for a driving evaluation with a driving rehabilitation specialist prior to receiving clearance to return to driving. More detailed information about such an evaluation is provided in training segment 3a. If your client is unable to return to driving or plans to utilize public transportation, you may wish to work with your client to identify resources for public transportation and specialized transportation services for clients with disabilities. Alternatively, you may need to work with your client to identify other transportation alternatives, such as a family member or friend who might provide transportation to and from the work setting for your client. Return to top or Continue
9 Sources of financial support Although unfortunate, it is a reality that funding issues will limit the extent to which your client with TBI will be able to access services, supports, and technologies that may maximize their daily functioning and quality of life. A social worker might have helped your client to identify all the possible current financial, material, and social support resources available to your client, but as a VR counselor it is not a bad idea to also have knowledge of these resources. Social workers are often in the position to help clients, such as yours, to identify community resources and helping him or her to network to obtain resources. Potential areas of financial or resource assistance for that may have been suggested to your client might include, but are not limited to: Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) Medicare Medicaid Worker s Compensation Crime Victims Assistance County medical care assistance Advocacy, Inc. Legal Aid Energy Assistance Programs Identification of local services offered on sliding-scale or pro bono basis While social workers may have been involved in assisting your client in identifying community resources, it will be important that you, the vocational counselor, have a working knowledge of appropriate resources and their eligibility requirements (e.g., residency, citizenship). You may be a key person in directing persons with TBI and their family members to agencies and services that may improve their community participation and quality of life. Preparing written
10 handouts that may facilitate the application process, such as listing the types of information that will be needed to complete applications (e.g., identification, proof of address through utility bill, etc.) may also be useful. In some cases, you may need to assist your client and/or his or her family in completing application materials, especially if reading level is an issue or if the person s primary language is not English. You have now completed the self-study material for this module segment. Options: Return to the top View references for this module segment Continue on to the next segment in this module Evaluate the module (but don t forget, this is just one of three segments for this module) Obtain further information on obtaining continuing education credit
11 References 1. Walker WC, Kreutzer JS, Witol AD. Level of care options for the low-functioning brain injury survivor. Brain Injury 1996; 10: Commission on Accreditation of Rehabilitation Facilities, Some of the information in this guide was adapted, with permission of the authors, from the following sources: Sander, A.M. Picking Up the Pieces: A Guide for Family Members after TBI. 2002, Baylor College of Medicine. Struchen, M.A., Clark, A.N. Systematic Approach to Social Work Practice: Working with Clients with Traumatic Brain Injury Baylor College of Medicine. Return to top or Continue to Training Session 3c